Provider Demographics
NPI:1932260882
Name:SOUSSAN, ROSE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:
Last Name:SOUSSAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 FANNING ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5308
Mailing Address - Country:US
Mailing Address - Phone:718-442-2924
Mailing Address - Fax:718-442-2924
Practice Address - Street 1:162 FANNING ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5308
Practice Address - Country:US
Practice Address - Phone:718-442-2924
Practice Address - Fax:718-442-2924
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR030665-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7334050OtherG.H.I.
NYP2878514OtherOXFORD
NY02367233Medicaid
NYNON401Medicare ID - Type UnspecifiedMEDICARE